War has always been an impetus for change. As wars advance and we produce new technology to kill people, we also produce new methods and tactics to save people.
The Canadian experience in Afghanistan is no exception. I joined the military as a medic in 1998 and we were taught St John first aid methodology. As we got to the next level of training, it was the civilian paramedic programs that gave us the knowledge to save lives. All medics are trained to treat according to the way we fight; unfortunately it is always based on the last war. The Canadian Forces (CF) last war was the conflict in Korea, with some smattering of ideas from the Vietnam War. After September 11, the CF was tasked to send troops to Kandahar; the homeland of the Taliban and its Arab guests, Al Queda. As part of our training, an American gave a brief one hour lecture on Tactical Combat Casualty Care (TCCC). The lecture, although forgotten by many, was not forgotten by the medics and those with medical knowledge. They realized very quickly that this was an important and revolutionary approach to battlefield casualty care4.
TCCC was developed by Capt. Frank Butler of the US Navy in 1996 and is now in use in the most advanced western professional armies. TCCC teaches that the best medicine is fire superiority; in other words "bullets down range". Our job is to first kill the enemy or make the battle move from the current position, so that the wounded can be assessed. When bullets and explosions are happening, there is no time for advanced airway methods or even spinal precautions. These treatments have to wait until after the fire fight, or after the wounded soldier has been moved to a safe location2. Within TCCC there are three phases: 1) Care Under Fire, 2) Tactical Field Care, and 3) Casualty Evacuation. In the Care Under Fire phase, we focus on what kills a person the quickest. statistically, blood loss is the number one killer of treatable injuries, followed by tension pneumothorax and airway concerns2.
Tactical Field Care occurs only when the patient and the medic are in a safe position. TCCC teaches that all extremity bleeds should have a tourniquet. Once the main causes of death in combat are addressed, then the medic can fall back to the traditional ABC methodology and secondary survey and stabilization2,4.
The wounded soldier is then evacuated by helicopter directly to one of the best battle field hospitals in the world (Role 3 facility at Kandahar Air Base). The aim is to reduce time spent on the roads due to the enemy threat and risk of improvised explosive devices4. Casualty evacuation directly to the Role 3 allows the precise surgical and medical teams to take over.
G-wagon driven by MCpl Franklin after attack by a suicide bomber.
Canada has had a challenging time determining the best placement of TCCC and the two day introduction course called Combat First Aid (CFA). After the friendly fire incident in 2002, Cpl. Chris Kopp wrote a Briefing Note telling the CF of this program from the US and how it was used on our troops in the incident and the decisions that were made that directly saved lives4. Not because they used their traditional training, but because they went against it. In the After Action review of the incident, TCCC was singled out and it was recommended that more troops be placed on the course. However, reports in 2007 indicated that "the director of the military's health services branch, Col. Maureen Haberstock, has criticized the proposal, saying combat casualty care is training that should be reserved for 'exceptional' soldiers." Lt.-Cmdr. Ian Torrie, a physician expert in combat casualty training, was further quoted as saying in an interview: "The people who are going to get this extra training, you really want your brightest person. You really don't want everybody to have it. Some of the skills taught, if performed unnecessarily or incorrectly can be harmful, or even fatal."1
However the medics that worked in the field knew the value of TCCC and began to teach CFA. They knew that in the midst of a fire fight you could not count on having the best and brightest standing beside you. You want everyone to have the training required to save lives, including medics who know how to shoot and infantry who know TCCC. The field medics began to teach the troops the skills of TCCC to give them the medical tools necessary for survival.
Helicopter evacuation of wounded soldier.
From a personal perspective, on January 15, 2006 while driving in a four vehicle convoy, my G-wagon was hit by a car carrying 56 kilos of explosive. The suicide blast killed Glen Berry, the VIP in my vehicle, and severely wounded myself and two other soldiers. The training that we had given our troops saved our lives. I am now a double above the knee amputee and was saved by Cpl. Jake Petton who put a tourniquet on my shattered left leg. The other two soldiers who were in the vehicle are still serving in the CF despite head injuries. They survived because of the interventions of their fellow infantry while myself, their medic, was wounded on the ground.
Combat First Aid is now given to all troops going overseas and we are seeing, as a direct result of this and the advanced TCCC courses (given to soldiers and medics that train the Afghan army and Police), that fewer CF troops are dying of wounds. If we use historical examples to compare casualty rates for the War in Afghanistan, the expectation is 3500 wounded and just about 340 fallen; instead we have 660 wounded and 128 fallen3. The reason for the low numbers is the quick reaction that the leadership has taken in bringing armoured vehicles and equipment into the fight and the acceptance that TCCC saves lives.
Arguments over the value of TCCC have fallen to the wayside.